Chapter 45 - Anticoagulants, Antiplatelets, and Thrombolytics

Which intervention is essential before the nurse administers tenecteplase (TNKase)? Perform all necessary venipunctures. Administer aminocaproic acid (Amicar). Have the patient void. Assess for allergies to iodine.

Perform all necessary venipunctures. TNKase is a thrombolytic agent that can interfere with the body's clotting ability. Therefore, all invasive procedures should be completed before administering this drug.

The patient asks the nurse to explain the difference between dalteparin (Fragmin) and heparin. Which response by the nurse is accurate? "There is no real difference. Dalteparin is preferred because it is less expensive." "Dalteparin is a low-molecular-weight heparin that is more predictable in its effect and has a lower risk of bleeding." "I'm not sure why some health care providers choose dalteparin and some heparin. You should ask your doctor." "The only difference is that heparin dosing is based on the patient's weight."

"Dalteparin is a low-molecular-weight heparin that is more predictable in its effect and has a lower risk of bleeding." A low-molecular-weight heparin is more predictable in its effect than regular heparin. Dalteparin (Fragmin) is more expensive than heparin and is dosed based on the patient's weight. It is not appropriate to provide the patient with no instruction other than to simply refer to the health care provider.

The nurse evaluates that the patient has understood discharge teaching regarding warfarin (Coumadin) based on which statement? "I will double my dose if I forget to take it the day before." "I should keep taking ibuprofen for my arthritis." "I should decrease the dose if I start bruising easily." "I should use a soft toothbrush for dental hygiene."

"I should use a soft toothbrush for dental hygiene." This statement is accurate and will reduce the risk of bleeding. Ibuprofen will potentiate bleeding. The patient should call the health care provider if experiencing excessive bruising.

A patient is receiving warfarin (Coumadin) for a chronic condition. Which patient statement requires immediate action by the nurse? "I will avoid contact sports." "I will take my medication in the early evening each day." "I will increase dark-green, leafy vegetables in my diet." "I will contact my health care provider if I develop excessive bruising."

"I will increase dark-green, leafy vegetables in my diet." Dark-green, leafy vegetables are rich in vitamin K, which would antagonize the effects of warfarin. Rather than increase the intake of these, it is important to maintain a consistent daily intake of vitamin K. The patient should monitor his or her incidence of bruising carefully. The medication will usually be ordered for the patient to take in the morning.

A patient is started on warfarin (Coumadin) therapy while also receiving intravenous heparin. The patient is concerned about the risk for bleeding. What will the nurse tell the patient? "Your concern is valid. I will call the doctor to discontinue the heparin." "It usually takes about 3 days to achieve a therapeutic effect for warfarin, so the heparin is continued until the warfarin is therapeutic." "Because of your valve replacement, it is especially important for you to be anticoagulated. The heparin and warfarin together are more effective than one alone." "Because you are now up and walking, you have a higher risk of blood clots and therefore need to be on both medications."

"It usually takes about 3 days to achieve a therapeutic effect for warfarin, so the heparin is continued until the warfarin is therapeutic." Warfarin works by decreasing the production of clotting factors. However, it takes approximately 3 days for the body to metabolize present clotting factors and thus achieve a therapeutic anticoagulant effect. Because of this, heparin is continued until this is achieved.

A patient is receiving an intravenous heparin drip. Which laboratory value requires immediate action by the nurse?** Platelet count of 150,000 Activated partial thromboplastin time (aPTT) of 120 seconds INR of 1.0 Blood urea nitrogen (BUN) level of 12 mg/dL

Activated partial thromboplastin time (aPTT) of 120 seconds The aPTT value of 120 seconds is too prolonged. The heparin drip should be shut off for an hour. The typical aPTT normal reference range for a patient on anticoagulant therapy is 30 to 85 seconds (range may vary slightly depending on the laboratory used). The normal range for BUN is 7 to 20 mg/dL, and the normal platelet range is 150,000 to 450,000.

The patient has an international normalized ratio (INR) value of 1.5. In response to this, the nurse could anticipate the health care provider placing which order? Administer an additional dose of warfarin (Coumadin). Hold the next dose of warfarin (Coumadin). Increase the heparin drip rate. Administer protamine sulfate.

Administer an additional dose of warfarin (Coumadin). A therapeutic INR is 2 to 3. The patient needs more warfarin to reach a therapeutic level.

A patient has arrived at the emergency department and requires immediate surgery. He has been receiving heparin. Which intervention is essential? Teach the patient about the phenytoin. Administer protamine sulfate. Assess the INR before surgery. Administer vitamin K.

Administer protamine sulfate. Protamine sulfate binds with heparin in the bloodstream to inactivate it and thus reverse its effect. Allowing the patient to undergo surgery while receiving heparin would be life-threatening. The situation should be reversed immediately, without the nurse taking the time to assess the INR or administer vitamin K. It is not appropriate to teach the patient about phenytoin since it has not been ordered for the patient.

A nurse is preparing to administer enoxaparin sodium (Lovenox) to a patient for prevention of deep vein thrombosis. Which is an essential nursing intervention? Draw up the medication in a syringe with a 22-gauge, 1½-inch needle. Utilize the Z-track method to inject the medication. Administer the medication into subcutaneous tissue. Rub the administration site after injecting.

Administer the medication into subcutaneous tissue. Enoxaparin (Lovenox) is a low-molecular-weight heparin that is administered subcutaneously. The site should not be rubbed after injection, and the Z-track method also should never be used to administer enoxaparin sodium (Lovenox). The use of 22-gauge, 1½-inch needle is more appropriate for administration of an IM injection.

Which nursing intervention is essential for the patient receiving alteplase (Activase)? Assess for reperfusion dysrhythmias. Monitor liver enzymes. Administer prescribed vitamin K if bruising is observed. Monitor blood pressure and stop the medication if blood pressure drops below 110 systolic.

Assess for reperfusion dysrhythmias. Alteplase (Activase) can cause bleeding as well as reperfusion dysrhythmias. Alteplase does not directly affect liver enzymes. Vitamin K will not reverse the effects of alteplase. Vital sign changes can alert the nurse to complications; however, a blood pressure below 110 systolic is not, in itself, cause for alarm.

A patient taking warfarin (Coumadin) asks for an aspirin for a headache. What is the nurse's best action? Administer 650 mg of acetylsalicylic acid (ASA) and reassess pain in 30 minutes. Teach the patient of potential drug interactions with anticoagulants. Explain to the patient that ASA is contraindicated and administer ibuprofen as ordered. Explain that the headache is an expected side effect and will subside shortly.

Teach the patient of potential drug interactions with anticoagulants. Patients taking an anticoagulant should not use medications that would further increase the risk of bleeding, which includes aspirin as well as ibuprofen. Aspirin should not be administered to the patient taking other anticoagulants, unless it is ordered specifically as a low-dose daily therapy. Ibuprofen is not the best choice of medication for the patient receiving Coumadin. Tylenol (acetaminophen) would be preferred for pain relief. Headache is not an expected side effect of Coumadin therapy.

A patient who has been taking warfarin (Coumadin) is admitted with coffee-ground emesis. What can the nurse anticipate being prescribed for this patient? Vitamin E Vitamin K Protamine sulfate Calcium gluconate

Vitamin K